CMS Increasing Medicare Advantage Audits
What happens when CMS increases Medicare Advantage audits nearly tenfold and expands its team of medical record reviewers from just 40 coders to approximately 2,000?
It means every diagnosis submitted for Medicare Advantage reimbursement is more likely to be reviewed. Finding chronic conditions is important, but every diagnosis must also be backed by clear, complete documentation.
That's where ForeSee Medical can help.
ForeSee Medical's AI-powered ForeSee ESP® identifies clinically supported chronic conditions and helps providers create documentation that meets CMS requirements. Even better, ForeSee ESP® is the only HCC AI software with InstaVu®. With one click, the original source document—such as a hospital discharge summary or specialist consult note—instantly appears on the screen with the supporting diagnosis highlighted. Providers and coders can quickly see the evidence without searching through hundreds of pages of records.
CMS Is Expanding RADV Audits
CMS recently announced a major expansion of its Risk Adjustment Data Validation (RADV) audit program to improve oversight of Medicare Advantage payments.
As part of the expansion, CMS plans to:
Audit all eligible Medicare Advantage contracts in newly initiated audits.
Increase annual audit volume from about 60 Medicare Advantage plans to approximately 550 plans.
Expand its medical coder staff from about 40 coders to approximately 2,000 coders.
These changes mean many more diagnoses will be reviewed to make sure they are supported by the patient's medical record.
Why This Matters
In Medicare Advantage, chronic conditions help determine a patient's HCC risk score, which affects reimbursement.
The process is simple:
AI identifies a possible chronic condition.
The provider confirms and documents it.
An ICD-10 code is submitted on the claim.
The health plan sends the information to CMS.
If the diagnosis is properly documented, it contributes to the patient's HCC risk score.
Many organizations buy HCC risk adjustment coding software because they don't want to miss chronic conditions. But today, in order to receive the revenue you deserve, the challenge is making sure every submitted diagnosis can pass a RADV audit. If the documentation doesn't support the diagnosis, CMS may recover the payment.
How ForeSee Medical Helps
ForeSee Medical helps organizations capture more supported HCCs while improving documentation quality.
Using AI in healthcare, ForeSee reviews physician notes, hospital records, consult notes, lab results, medications, and other clinical documents to identify supported chronic conditions.
With InstaVu®, every suggested diagnosis is linked directly to the supporting medical record. Providers and coders can instantly verify the evidence with a single click, making reviews faster and helping reduce audit risk.
ForeSee helps organizations:
Find more clinically supported HCCs
Improve CMS-compliant documentation
Reduce the risk of unsupported diagnoses
Increase coding accuracy
Instantly locate supporting evidence with InstaVu®
The Bottom Line
CMS is greatly increasing Medicare Advantage audits. With audits expanding from approximately 60 plans to about 550 plans each year and medical reviewers growing from 40 to approximately 2,000 coders, documentation will be under more scrutiny than ever before.
Success in risk adjustment is no longer just about finding more diagnoses. It's about making sure every diagnosis is supported by clear clinical evidence.
ForeSee ESP® helps organizations do both. By combining AI-powered disease identification with the industry's only InstaVu® technology, ForeSee helps providers maximize appropriate reimbursement while staying prepared for increasing CMS audits.
Blog by: The ForeSee Medical Team